{"version":"1.0.0","segments":[{"startTime":0.545,"endTime":3.255,"body":"♪ (music) ♪"},{"startTime":3.255,"endTime":5.605,"body":"(Cathy) Hi, welcome"},{"startTime":3.255,"endTime":5.605,"body":"to \u003ci\u003eHarrison's Podclass\u003c/i\u003e,"},{"startTime":5.605,"endTime":8.655,"body":"where we discuss important concepts"},{"startTime":5.605,"endTime":8.655,"body":"in internal medicine."},{"startTime":8.655,"endTime":11.065,"body":"- I'm Cathy Handy."},{"startTime":8.655,"endTime":11.065,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":11.065,"endTime":13.825,"body":"and we're coming to you"},{"startTime":11.065,"endTime":13.825,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"Episode 28","startTime":15.752,"endTime":19.532,"body":"A 63-Year-Old with a Skin Lesion."},{"speaker":"So, here's the question","startTime":21.764,"endTime":24.594,"body":"a 63-year-old woman"},{"speaker":"So, here's the question","startTime":21.764,"endTime":24.594,"body":"with chronic kidney disease"},{"speaker":"So, here's the question","startTime":24.594,"endTime":27.644,"body":"is maintained"},{"speaker":"So, here's the question","startTime":24.594,"endTime":27.644,"body":"on daily peritoneal dialysis."},{"speaker":"So, here's the question","startTime":27.644,"endTime":29.935,"body":"Her past medical history"},{"speaker":"So, here's the question","startTime":27.644,"endTime":29.935,"body":"is notable for hypertension"},{"speaker":"So, here's the question","startTime":29.935,"endTime":31.435,"body":"and atrial fibrillation."},{"speaker":"So, here's the question","startTime":31.435,"endTime":34.635,"body":"Her medications include"},{"speaker":"So, here's the question","startTime":31.435,"endTime":34.635,"body":"losartan and warfarin."},{"speaker":"So, here's the question","startTime":34.635,"endTime":38.345,"body":"Two days ago, she noticed"},{"speaker":"So, here's the question","startTime":34.635,"endTime":38.345,"body":"a small painful nodule on her abdomen"},{"speaker":"So, here's the question","startTime":38.345,"endTime":40.505,"body":"that has progressed"},{"speaker":"So, here's the question","startTime":38.345,"endTime":40.505,"body":"to involve skin necrosis"},{"speaker":"So, here's the question","startTime":40.505,"endTime":43.085,"body":"and ulceration of the abdominal wall."},{"speaker":"So, here's the question","startTime":43.085,"endTime":45.495,"body":"Okay, Cathy, what do you think"},{"speaker":"So, here's the question","startTime":43.085,"endTime":45.495,"body":"so far of this?"},{"speaker":"So, here's the question","startTime":45.495,"endTime":48.255,"body":"(Cathy) Painful skin nodules"},{"speaker":"So, here's the question","startTime":45.495,"endTime":48.255,"body":"with necrosis and ulceration"},{"speaker":"So, here's the question","startTime":48.255,"endTime":51.895,"body":"in someone who is on dialysis,"},{"speaker":"So, here's the question","startTime":48.255,"endTime":51.895,"body":"makes me think of calciphylaxis."},{"speaker":"So, here's the question","startTime":51.895,"endTime":55.085,"body":"This is also called"},{"speaker":"So, here's the question","startTime":51.895,"endTime":55.085,"body":"calcific uremic arteriolopathy"},{"speaker":"So, here's the question","startTime":55.085,"endTime":58.325,"body":"and it is seen almost exclusive"},{"speaker":"So, here's the question","startTime":55.085,"endTime":58.325,"body":"in patients who are on dialysis."},{"speaker":"So, here's the question","startTime":58.325,"endTime":61.275,"body":"But the other disorder to think of"},{"speaker":"So, here's the question","startTime":58.325,"endTime":61.275,"body":"in a patient on warfarin therapy"},{"speaker":"So, here's the question","startTime":61.275,"endTime":63.105,"body":"is warfarin-induced skin necrosis,"},{"speaker":"So, here's the question","startTime":63.105,"endTime":65.475,"body":"but that is seen during"},{"speaker":"So, here's the question","startTime":63.105,"endTime":65.475,"body":"initial warfarin administration"},{"speaker":"So, here's the question","startTime":65.475,"endTime":67.715,"body":"because you get protein C deficiency"},{"speaker":"So, here's the question","startTime":67.715,"endTime":70.305,"body":"which causes"},{"speaker":"So, here's the question","startTime":67.715,"endTime":70.305,"body":"a transient hypercoagulable state"},{"speaker":"So, here's the question","startTime":70.305,"endTime":72.425,"body":"and that in turn leads"},{"speaker":"So, here's the question","startTime":70.305,"endTime":72.425,"body":"to the vascular occlusion"},{"speaker":"So, here's the question","startTime":72.425,"endTime":75.335,"body":"and tissue infarction"},{"speaker":"So, here's the question","startTime":72.425,"endTime":75.335,"body":"which produces the ulceration."},{"speaker":"So, here's the question","startTime":75.335,"endTime":77.685,"body":"(Charlie) But with"},{"speaker":"So, here's the question","startTime":75.335,"endTime":77.685,"body":"the painful skin nodule,"},{"speaker":"So, here's the question","startTime":77.685,"endTime":80.015,"body":"don't you have to think"},{"speaker":"So, here's the question","startTime":77.685,"endTime":80.015,"body":"of infectious causes also?"},{"speaker":"So, here's the question","startTime":80.015,"endTime":81.135,"body":"(Cathy) Yeah, absolutely,"},{"speaker":"So, here's the question","startTime":81.135,"endTime":82.745,"body":"and if the patient were neutropenic,"},{"speaker":"So, here's the question","startTime":82.745,"endTime":86.315,"body":"a necrotic nodule that you could see"},{"speaker":"So, here's the question","startTime":82.745,"endTime":86.315,"body":"would be ecthyma gangrenosum"},{"speaker":"So, here's the question","startTime":86.315,"endTime":89.585,"body":"and that's due to pseudomonas,"},{"speaker":"So, here's the question","startTime":86.315,"endTime":89.585,"body":"or a disseminated fungal infection."},{"speaker":"So, here's the question","startTime":89.585,"endTime":92.213,"body":"But we don't have any information"},{"speaker":"So, here's the question","startTime":89.585,"endTime":92.213,"body":"that this patient is neutropenic"},{"speaker":"So, here's the question","startTime":92.213,"endTime":95.143,"body":"and it sounds like there have been"},{"speaker":"So, here's the question","startTime":92.213,"endTime":95.143,"body":"no recent changes in medication,"},{"speaker":"So, here's the question","startTime":95.143,"endTime":97.943,"body":"so I would go with calciphylaxis"},{"speaker":"So, here's the question","startTime":95.143,"endTime":97.943,"body":"as the most likely cause,"},{"speaker":"So, here's the question","startTime":97.943,"endTime":99.643,"body":"given the information that we have."},{"speaker":"So, here's the question","startTime":99.643,"endTime":102.903,"body":"(Charlie) What's the pathophysiologic"},{"speaker":"So, here's the question","startTime":99.643,"endTime":102.903,"body":"mechanism of calciphylaxis?"},{"speaker":"So, here's the question","startTime":102.903,"endTime":104.463,"body":"(Cathy) So, what you see pathologically"},{"speaker":"So, here's the question","startTime":104.463,"endTime":106.543,"body":"is that there is evidence"},{"speaker":"So, here's the question","startTime":104.463,"endTime":106.543,"body":"of vascular occlusion"},{"speaker":"So, here's the question","startTime":106.543,"endTime":110.923,"body":"in association with extensive vascular"},{"speaker":"So, here's the question","startTime":106.543,"endTime":110.923,"body":"and soft tissue calcification."},{"speaker":"So, here's the question","startTime":110.923,"endTime":113.126,"body":"A patient will first get"},{"speaker":"So, here's the question","startTime":110.923,"endTime":113.126,"body":"livedo reticularis"},{"speaker":"So, here's the question","startTime":113.126,"endTime":116.426,"body":"and then that advances"},{"speaker":"So, here's the question","startTime":113.126,"endTime":116.426,"body":"to patches of ischemic necrosis."},{"speaker":"So, here's the question","startTime":116.426,"endTime":119.756,"body":"You typically find it on the legs,"},{"speaker":"So, here's the question","startTime":116.426,"endTime":119.756,"body":"thighs, abdomen, and breasts"},{"speaker":"So, here's the question","startTime":119.756,"endTime":122.156,"body":"and a skin biopsy"},{"speaker":"So, here's the question","startTime":119.756,"endTime":122.156,"body":"can be used for diagnosis"},{"speaker":"So, here's the question","startTime":122.156,"endTime":125.076,"body":"if you're not sure"},{"speaker":"So, here's the question","startTime":122.156,"endTime":125.076,"body":"based on the clinical presentation."},{"speaker":"So, here's the question","startTime":125.076,"endTime":127.026,"body":"(Charlie) So, this question asks,"},{"speaker":"So, here's the question","startTime":127.026,"endTime":131.736,"body":"all the following statements"},{"speaker":"So, here's the question","startTime":127.026,"endTime":131.736,"body":"regarding her condition are true except:"},{"speaker":"So, here's the question","startTime":131.743,"endTime":136.786,"body":"option A says, oral calcium"},{"speaker":"So, here's the question","startTime":131.743,"endTime":136.786,"body":"supplementation may be a risk factor;"},{"speaker":"So, here's the question","startTime":136.786,"endTime":141.116,"body":"option B says, pathologically,"},{"speaker":"So, here's the question","startTime":136.786,"endTime":141.116,"body":"there is vascular occlusion;"},{"speaker":"So, here's the question","startTime":141.119,"endTime":145.447,"body":"option C says,"},{"speaker":"So, here's the question","startTime":141.119,"endTime":145.447,"body":"pseudomonas co-infection is typical;"},{"speaker":"So, here's the question","startTime":145.447,"endTime":150.685,"body":"option D says, severe hyperparathyroidism"},{"speaker":"So, here's the question","startTime":145.447,"endTime":150.685,"body":"may \u003ci\u003enot\u003c/i\u003e be present;"},{"speaker":"So, here's the question","startTime":150.685,"endTime":155.125,"body":"and E says, warfarin is a risk factor"},{"speaker":"So, here's the question","startTime":150.685,"endTime":155.125,"body":"for the development of the lesion."},{"speaker":"So, here's the question","startTime":155.125,"endTime":157.723,"body":"(Cathy) So, let's start with A."},{"speaker":"So, here's the question","startTime":155.125,"endTime":157.723,"body":"That's true."},{"speaker":"So, here's the question","startTime":157.723,"endTime":160.883,"body":"Oral calcium supplementation"},{"speaker":"So, here's the question","startTime":157.723,"endTime":160.883,"body":"is considered a risk factor"},{"speaker":"So, here's the question","startTime":160.883,"endTime":162.183,"body":"and as is warfarin."},{"speaker":"So, here's the question","startTime":162.183,"endTime":163.813,"body":"So, E is also true."},{"speaker":"So, here's the question","startTime":163.813,"endTime":167.763,"body":"Other risk factors for calciphylaxis"},{"speaker":"So, here's the question","startTime":163.813,"endTime":167.763,"body":"would include hyperphosphatemia,"},{"speaker":"So, here's the question","startTime":167.763,"endTime":172.323,"body":"obesity, diabetes, hypercoagulable states,"},{"speaker":"So, here's the question","startTime":167.763,"endTime":172.323,"body":"and also hypoalbuminemia,"},{"speaker":"So, here's the question","startTime":172.323,"endTime":175.823,"body":"inflammatory and autoimmune diseases,"},{"speaker":"So, here's the question","startTime":172.323,"endTime":175.823,"body":"and recurrent skin trauma."},{"speaker":"So, here's the question","startTime":175.823,"endTime":178.793,"body":"It is more commonly found in females"},{"speaker":"So, here's the question","startTime":175.823,"endTime":178.793,"body":"compared to males,"},{"speaker":"So, here's the question","startTime":178.793,"endTime":180.093,"body":"and the incidence is increasing,"},{"speaker":"So, here's the question","startTime":180.093,"endTime":182.463,"body":"although it is not really clear"},{"speaker":"So, here's the question","startTime":180.093,"endTime":182.463,"body":"why that's the case."},{"speaker":"So, here's the question","startTime":182.463,"endTime":185.683,"body":"(Charlie) Tell me more about the warfarin."},{"speaker":"So, here's the question","startTime":182.463,"endTime":185.683,"body":"Why is that ought to be a risk factor?"},{"speaker":"So, here's the question","startTime":185.683,"endTime":188.483,"body":"(Cathy) With regards to warfarin"},{"speaker":"So, here's the question","startTime":185.683,"endTime":188.483,"body":"since the patient here is on it,"},{"speaker":"So, here's the question","startTime":188.483,"endTime":190.923,"body":"it's commonly used"},{"speaker":"So, here's the question","startTime":188.483,"endTime":190.923,"body":"in hemodialysis patients"},{"speaker":"So, here's the question","startTime":190.923,"endTime":192.663,"body":"and one of the effects of warfarin therapy"},{"speaker":"So, here's the question","startTime":192.663,"endTime":197.223,"body":"is to decrease the vitamin K-dependent"},{"speaker":"So, here's the question","startTime":192.663,"endTime":197.223,"body":"regeneration of matrix GLA protein."},{"speaker":"So, here's the question","startTime":197.223,"endTime":200.833,"body":"This latter protein is important"},{"speaker":"So, here's the question","startTime":197.223,"endTime":200.833,"body":"in preventing vascular calcification."},{"speaker":"So, here's the question","startTime":200.833,"endTime":204.003,"body":"So, warfarin treatment is considered"},{"speaker":"So, here's the question","startTime":200.833,"endTime":204.003,"body":"a risk factor for calciphylaxis"},{"speaker":"So, here's the question","startTime":204.003,"endTime":206.673,"body":"and if a patient develops"},{"speaker":"So, here's the question","startTime":204.003,"endTime":206.673,"body":"this syndrome while on warfarin,"},{"speaker":"So, here's the question","startTime":206.673,"endTime":208.413,"body":"this medication should be discontinued"},{"speaker":"So, here's the question","startTime":208.413,"endTime":211.983,"body":"and you can replace it"},{"speaker":"So, here's the question","startTime":208.413,"endTime":211.983,"body":"with alternative forms of anticoagulation."},{"speaker":"So, here's the question","startTime":211.983,"endTime":214.333,"body":"(Charlie) Okay."},{"speaker":"So, here's the question","startTime":211.983,"endTime":214.333,"body":"So, that rules out two of the choices."},{"speaker":"So, here's the question","startTime":214.333,"endTime":215.653,"body":"And you also mentioned previously"},{"speaker":"So, here's the question","startTime":215.653,"endTime":218.093,"body":"that pathologically"},{"speaker":"So, here's the question","startTime":215.653,"endTime":218.093,"body":"there is vascular occlusion,"},{"speaker":"So, here's the question","startTime":218.093,"endTime":220.343,"body":"so, we can rule out option B as well."},{"speaker":"So, here's the question","startTime":220.343,"endTime":221.843,"body":"What about C and D?"},{"speaker":"So, here's the question","startTime":221.843,"endTime":223.283,"body":"(Cathy) So, D is true."},{"speaker":"So, here's the question","startTime":223.283,"endTime":226.283,"body":"Severe hyperparathyroidism"},{"speaker":"So, here's the question","startTime":223.283,"endTime":226.283,"body":"is not always present."},{"speaker":"So, here's the question","startTime":226.283,"endTime":228.643,"body":"Originally, it was ascribed"},{"speaker":"So, here's the question","startTime":226.283,"endTime":228.643,"body":"to severe abnormalities"},{"speaker":"So, here's the question","startTime":228.643,"endTime":231.643,"body":"in calcium and phosphorus control"},{"speaker":"So, here's the question","startTime":228.643,"endTime":231.643,"body":"in dialysis patients,"},{"speaker":"So, here's the question","startTime":231.643,"endTime":235.113,"body":"and that's usually associated"},{"speaker":"So, here's the question","startTime":231.643,"endTime":235.113,"body":"with advanced hyperparathyroidism."},{"speaker":"So, here's the question","startTime":235.113,"endTime":237.413,"body":"However, more recently,"},{"speaker":"So, here's the question","startTime":235.113,"endTime":237.413,"body":"calciphylaxis has been seen"},{"speaker":"So, here's the question","startTime":237.413,"endTime":241.443,"body":"with increasing frequency, in the absence"},{"speaker":"So, here's the question","startTime":237.413,"endTime":241.443,"body":"of severe hyperparathyroidism."},{"speaker":"So, here's the question","startTime":241.444,"endTime":243.724,"body":"The exact reason for this isn't clear."},{"speaker":"So, here's the question","startTime":243.724,"endTime":246.404,"body":"(Charlie) Okay."},{"speaker":"So, here's the question","startTime":243.724,"endTime":246.404,"body":"So, C is a false statement."},{"speaker":"So, here's the question","startTime":246.404,"endTime":249.284,"body":"Pseudomonas co-infection,"},{"speaker":"So, here's the question","startTime":246.404,"endTime":249.284,"body":"in fact, is \u003ci\u003enot\u003c/i\u003e typical"},{"speaker":"So, here's the question","startTime":249.284,"endTime":251.844,"body":"in patients with calciphylaxis, right?"},{"speaker":"So, here's the question","startTime":251.844,"endTime":254.844,"body":"(Cathy) Yeah, I'm not aware of any"},{"speaker":"So, here's the question","startTime":251.844,"endTime":254.844,"body":"literature supporting bacterial infection"},{"speaker":"So, here's the question","startTime":254.844,"endTime":257.284,"body":"as typically co-occurring"},{"speaker":"So, here's the question","startTime":254.844,"endTime":257.284,"body":"with calciphylaxis."},{"speaker":"So, here's the question","startTime":257.284,"endTime":259.604,"body":"And as I mentioned before,"},{"speaker":"So, here's the question","startTime":257.284,"endTime":259.604,"body":"if the patient were neutropenic,"},{"speaker":"So, here's the question","startTime":259.604,"endTime":262.114,"body":"then ecthyma gangrenosum"},{"speaker":"So, here's the question","startTime":259.604,"endTime":262.114,"body":"may be in the differential,"},{"speaker":"So, here's the question","startTime":262.114,"endTime":263.744,"body":"but that's not the case here."},{"speaker":"So, here's the question","startTime":263.744,"endTime":266.084,"body":"(Charlie) Okay. So, what would you do"},{"speaker":"So, here's the question","startTime":263.744,"endTime":266.084,"body":"to help this patient?"},{"speaker":"So, here's the question","startTime":266.084,"endTime":267.774,"body":"(Cathy) First, you start off"},{"speaker":"So, here's the question","startTime":266.084,"endTime":267.774,"body":"with supportive care"},{"speaker":"So, here's the question","startTime":267.774,"endTime":270.544,"body":"that would include, for me,"},{"speaker":"So, here's the question","startTime":267.774,"endTime":270.544,"body":"local wound care"},{"speaker":"So, here's the question","startTime":270.544,"endTime":272.629,"body":"and you can treat"},{"speaker":"So, here's the question","startTime":270.544,"endTime":272.629,"body":"with hyperbaric oxygen"},{"speaker":"So, here's the question","startTime":272.629,"endTime":273.949,"body":"if it's very severe,"},{"speaker":"So, here's the question","startTime":273.949,"endTime":276.729,"body":"and then intravenous thiosulfate"},{"speaker":"So, here's the question","startTime":273.949,"endTime":276.729,"body":"is also used."},{"speaker":"So, here's the question","startTime":276.729,"endTime":277.819,"body":"And, as I mentioned before,"},{"speaker":"So, here's the question","startTime":277.819,"endTime":281.469,"body":"in this patient I would change"},{"speaker":"So, here's the question","startTime":277.819,"endTime":281.469,"body":"the anticoagulation and stop the warfarin."},{"speaker":"So, here's the question","startTime":281.469,"endTime":283.669,"body":"(Charlie) Okay."},{"speaker":"So, here's the question","startTime":281.469,"endTime":283.669,"body":"So, the teaching point, in this case,"},{"speaker":"So, here's the question","startTime":283.669,"endTime":286.189,"body":"is that calciphylaxis"},{"speaker":"So, here's the question","startTime":283.669,"endTime":286.189,"body":"is most commonly seen"},{"speaker":"So, here's the question","startTime":286.189,"endTime":289.649,"body":"in patients with advanced kidney disease,"},{"speaker":"So, here's the question","startTime":286.189,"endTime":289.649,"body":"although it is not always,"},{"speaker":"So, here's the question","startTime":289.649,"endTime":291.509,"body":"and is caused by vascular occlusion"},{"speaker":"So, here's the question","startTime":291.509,"endTime":294.009,"body":"in association with extensive"},{"speaker":"So, here's the question","startTime":291.509,"endTime":294.009,"body":"vascular necrosis"},{"speaker":"So, here's the question","startTime":294.009,"endTime":296.189,"body":"and soft tissue calcification."},{"speaker":"So, here's the question","startTime":296.189,"endTime":299.869,"body":"Warfarin and calcium supplementation"},{"speaker":"So, here's the question","startTime":296.189,"endTime":299.869,"body":"are risk factors for its development"},{"speaker":"So, here's the question","startTime":299.869,"endTime":302.479,"body":"and patients-- taking care"},{"speaker":"So, here's the question","startTime":299.869,"endTime":302.479,"body":"of patients on renal dialysis"},{"speaker":"So, here's the question","startTime":302.479,"endTime":305.389,"body":"should be aware"},{"speaker":"So, here's the question","startTime":302.479,"endTime":305.389,"body":"of this complication of dialysis,"},{"speaker":"So, here's the question","startTime":305.389,"endTime":308.669,"body":"both hemodialysis and peritoneal dialysis."},{"speaker":"So, here's the question","startTime":308.669,"endTime":310.199,"body":"(Cathy) And to read more about this,"},{"speaker":"So, here's the question","startTime":310.199,"endTime":313.339,"body":"you can check out the \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"So, here's the question","startTime":310.199,"endTime":313.339,"body":"on Chronic Kidney Disease"},{"speaker":"So, here's the question","startTime":313.339,"endTime":315.789,"body":"and Disorders of the Kidney"},{"speaker":"So, here's the question","startTime":313.339,"endTime":315.789,"body":"and Urinary Tract."},{"speaker":"So, here's the question","startTime":315.789,"endTime":319.789,"body":"♪ (music) ♪"}]}